MEDICARE: HIS WILL WORLDWIDE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	FCL-092-168	NC

General Provider Information

NPI Number	:	1083994164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIS WILL WORLDWIDE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 58268
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27658-8268
Country	:	US
Telephone Number	:	919-673-7352
Fax Number	:	919-457-1450

Provider Business Practice Location Address
First Line	:	4114 JAMES RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-4903
Country	:	US
Telephone Number	:	919-872-1790
Fax Number	:	919-872-1790

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. BRENDA MICHELLE REID
Credential	:
Telephone Number	:	919-872-1790

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	08/22/2011

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